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<html lang="en" xmlns="http://www.w3.org/1999/xhtml">
<head>
    <meta charset="utf-8" />
    <title></title>
    <style type="text/css">
        #Select1 {
            width: 78px;
        }
    </style>
    <link href="../1033/STYLES/referrals/referralsmaster.css" rel="stylesheet" type="text/css" />
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<body>

    <table style="width: 100%; border-style: solid; border-width: 1px;">
        <tr>
            <td><label>Referral Information</label></td>
            <td><label>Locality Information</label></td>
            <td><label>Referral Status</label></td>

        </tr>
        <tr>
            <td>Date Referred:
                <input id="Text1" type="text" /></td>
            <td>Area:
                <input id="Text2" type="text" /></td>
            <td>Urgency:
                <select id="Select1" name="D1">
                    <option></option>
                </select></td>
        </tr>
        <tr>
            <td>Referred By:
                <select id="Select4" name="D4">
                    <option></option>
                </select></td>
            <td>Current Location:<select id="Select3" name="D3">
                <option></option>
                </select></td>
            <td>Stage:
                <select id="Select2" name="D2">
                    <option></option>
                </select></td>
        </tr>
        <tr>
            <td>Reason Referred:
                <select id="Select6" name="D6">
                    <option></option>
                </select></td>
            <td>&nbsp;</td>
            <td>Papers Location:
                <select id="Select5" name="D5">
                    <option></option>
                </select></td>
        </tr>
        <tr>
            <td>
                <textarea id="TextArea1" cols="20" name="S1" rows="2"></textarea></td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td>During Meeting</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td><label>1. Accept or Reject Referral</label></td>
            <td><label>2. Allocate if Neccessary</label></td>
            <td><label>3. Document Discussion</label></td>
        </tr>
        <tr>
            <td>Outcome:
                <select id="Select7" name="D7">
                    <option></option>
                </select></td>
            <td>Clinician 1: <select id="Select8" name="D8">
                <option></option>
                </select></td>
            <td>
                <textarea id="TextArea2" cols="20" name="S2" rows="2"></textarea></td>
        </tr>
        <tr>
            <td>&nbsp;</td>
            <td>Clinician 2:
                <select id="Select9" name="D9">
                    <option></option>
                </select></td>
            <td>Discuss next week Yes
                <input id="Radio1" checked="checked" name="R1" type="radio" value="V1" /> No<input id="Radio2" name="R2" type="radio" value="V1" /></td>
        </tr>
        <tr>
            <td colspan="2"><label>4. Track Progress - These fields must be completed as they relate to  Key Performance Indicators</label></td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td><label>review</label></td>
            <td><label>Response</label></td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td>This referral must be reviewed by:
                <input id="Text3" type="text" /></td>
            <td>The outcome of the review must be communicated to the referrer by:<input id="Text4" type="text" /></td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td><label>Assessment</label></td>
            <td><label>Report</label></td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td>This assessment must be completed by 17/06/2013</td>
            <td>A report on this referral must be sent by:</td>
            <td>Final Outcome: 
                <select id="Select10" name="D10">
                    <option></option>
                </select></td>
        </tr>
        <tr>
            <td>Assessment Date: <input id="Text5" type="text" /></td>
            <td>Date Report Sent: <input id="Text6" type="text" /></td>
            <td>&nbsp;</td>
        </tr>
        <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td>
                <input id="Button1" type="button" value="Update and Close" /></td>
        </tr>
    </table>

</body>
</html>